CurrentCommunity-CarePolicy N/A

DDAVP (desmopressin) Medical Benefit Medication Utilization Policy

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Defines coverage criteria for initial and continuation approval of desmopressin (DDAVP) for diabetes insipidus, Hemophilia A, and von Willebrand Disease; includes quantity limits, authorization period, and applicable HCPCS code(s).

Policy Summary

PayerCommunity-Care

PolicyDDAVP (desmopressin) Medical Benefit Medication Utilization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Last ReviewJul 1, 2023

Next Review Date

Key ActionFor initial approval, ensure desmopressin is prescribed by or in consultation with an endocrinologist for diabetes insipidus or by/with a hematologist for Hemophilia A or von Willebrand Disease; for continuation, document the patient is being monitored, responding appropriately, and remains appropriate to continue therapy.

SourceLink

POLICY UPDATE CHANGES

No material changes

3Covered Indications

1 yrAuthorization Period

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CurrentCommunity-CarePolicy N/A

DDAVP (desmopressin) Medical Benefit Medication Utilization Policy

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Policy Summary

PayerCommunity-Care

PolicyDDAVP (desmopressin) Medical Benefit Medication Utilization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Last ReviewJul 1, 2023

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material changes

3Covered Indications

1 yrAuthorization Period

Coverage Summary

Defines coverage criteria for initial and continuation approval of desmopressin (DDAVP) for diabetes insipidus, Hemophilia A, and von Willebrand Disease. Initial approval requires the medication be prescribed by, or in consultation with, an endocrinologist for diabetes insipidus or prescribed by, or in consultation with, a hematologist for Hemophilia A or von Willebrand Disease. Continuation requires diagnosis of one of the listed indications, that the medication be prescribed by, or in consultation with, a hematologist or endocrinologist, and documentation that the patient is being monitored and responding appropriately to treatment. The policy is designated as a medical-benefit medication and lists applicable HCPCS code(s) for billing purposes.

Key facts

Covered indicationsDiabetes insipidus; Hemophilia A; von Willebrand Disease (3 total)

Prescriber requirement (initial)Prescribed by, or in consultation with, an endocrinologist for diabetes insipidus or a hematologist for Hemophilia A/von Willebrand Disease

Continuation requirementsPrescribed by or in consultation with a hematologist or endocrinologist; patient monitored and responding to treatment

Authorization periodIf approved, coverage allowed for 1 year (subject to benefit changes)

HCPCS codeJ2597 — Injection, desmopressin acetate, per 1 mcg

Policy status / last reviewStatus: CURRENT; Last review: July 2023 (2023-07-01)

Initial Therapy Criteria

Initial Approval

Covered when ALL of the following are met:

ALL of the following

Indication (ONE of)
- Diagnosis of diabetes insipidus
- To be used for the management of temporary polyuria and polydipsia following head trauma or surgery
- Diagnosis of Hemophilia A
- Diagnosis of von Willebrand's Disease
Prescriber requirement (ONE of)

Continuation of Therapy Criteria

Continuation of Therapy

Covered when ALL of the following are met:

ALL of the following

Diagnosis (ONE of)
- Diabetes insipidus
- Temporary polyuria and polydipsia following head trauma or surgery
- Hemophilia A
- von Willebrand Disease
Prescribed by, or in consultation with, a hematologist or endocrinologist

Provider Actions

Prior Authorization

Prescriber specialty requirement

For initial approval, desmopressin must be prescribed by, or in consultation with, an endocrinologist for diabetes insipidus or by, or in consultation with, a hematologist for Hemophilia A or von Willebrand Disease.

J2597

Documentation Required

Continuation monitoring and response

Documentation must show the patient is being monitored, is responding appropriately to treatment, and remains appropriate to continue therapy for continuation of desmopressin.

J2597

Applicable Codes

Applicable HCPCS CodesHCPCSCovered

J2597

Injection, desmopressin acetate, per 1 mcg

Background

Desmopressin (DDAVP) is addressed as a medical-benefit medication for indications including diabetes insipidus, Hemophilia A, and von Willebrand Disease. Coverage requires appropriate prescriber specialty: endocrinologist involvement for diabetes insipidus and hematologist involvement for Hemophilia A or von Willebrand Disease, either as the prescriber or in consultation. For continuation of therapy, monitoring with documentation that the patient is responding appropriately to treatment is required. Definition: DDAVP -> Desmopressin acetate.

Clinical Evidence

Populate clinical evidence sources here if available (e.g., clinical trials, systematic reviews, treatment guidelines). Include study identifiers, key outcomes, and relevance to covered indications to support the policy criteria.